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1. A 60 year old white man presents to your clinic with head enlargement and decreased hearing. His gloves, shirts and pants continue to fit nicely, but his hats no longer go onto his head. He notes frontal headaches at time, and sometimes has aches in his anterior right shin. There is no family history of similar disorders.Physical examination is notable for a rather large appearing forehead with normal hair, normal external ear canals, and normal ocular movements. Air conduction appears decreased bilaterally. Blood pressure is 175/80 in both arms, pulse is regular at 72 bpm, and he is afebrile. There is a II/VI systolic ejection murmer at the lower left sternal border without radiation, and an S4 is present. Lungs are clear, and the remainder of the examination is normal except for mild pain on palpation of the right anterior tibia.Laboratory analysis shows normal electrolytes, glucose, BUN, creatinine. Calcium 8.4, phosphate 3.2, albumin 3.6gm/dL, AST (SGOT) 30, ALT (SGPT) 28, Alkaline Phosphatase 456U/ml (normal <85), Growth Hormone (pending), Insulin Like Growth Factor (pending), White Blood Count 8.4K/µl, HCT 39.6%, Platelets 323K/µl, MCV 84fl, ESR 32mm/hour.
   The most likely diagnosis is [1]:

   A. Acromegaly
   B. Paget's Disease
   C. Metastatic Lymphoma
   D. Osteomalacia
   E. Hyperparathyroidism

2. The diagnosis is made with [2]:

   A. MRI of the Brain
   B. Plain Radiographs
   C. White Blood Cell Scan
   D. Serum Vitamin D Metabolite levels
   E. Serum Parathyroid Hormone levels

3. The most appropriate treatment is [3]:

   A. Octreotide (Sandostatin®)
   B. Bisphosphonate Therapy (for example, alendronate, etidronate, pamidronate)
   C. Multiagent Chemotherapy ± Radiotherapy
   D. Vitamin D Replacement with Calcium
   E. Parathyroidectomy

4. Which of the following stimulates formation of Osteoblasts [4] ?

   A. Parathyroid Hormone (PTH)
   B. Vitamin D3
   C. Dihydroxyvitamin D3
   D. Interleukin 1 Receptor Antagonist (IL1-RA)
   E. Calcitonin

5. A 65 year old man with 15 years of rheumatoid arthritis on low dose prednisone (5mg each day) presents with new pain in his lumbar region. The pain is worse in the morning and is sometimes accompanied by fevers. He has no other medical problems, takes no other medications, and does not smoke. On examination his temperature is 100.2°F orally with otherwise normal vital signs. He has point tenderness in the L2-3 area. Routine blood analysis reveals a white cell count of 9.2K/µL with 80% neutrophils and 5% immature forms. The sedimentation rate is 111mm/hour. Electrolytes and renal function are within normal limits. The calcium is 6.8mg/dL with an albumin of 2.8gm/dL. The phosphate is normal. A radiograph of the lower spine shows degenerative joint disease with osteophytes and joint space narrowing. The most likely diagnosis is [5]:

   A. Compression Fractures
   B. Osteogenic Sarcoma
   C. Multiple Myeloma
   D. Osteonecrosis
   E. Osteomyelitis

6. A 48 year old thin white woman develops hot flashes and oligomenorrhea for which she consults you. She has a history of elevated cholesterol (total 230mg/dL); she quit smoking 4 years ago. A diagnosis of menopause is made. Which of the following is most likely to prevent osteoporotic fractures in the this woman [6] ?

   A. Calcitonin
   B. Calcium and Vitamin D supplementation
   C. Intermittant Parathyroid Hormone
   D. Estrogen Replacement Therapy
   E. Sodium Fluoride

7. The women in question #6 above develops a vertebral compression fracture despite prophylactic therapy. Which of the following is NOT helpful at preventing further fractures [7]?

   A. Calcitonin
   B. Bisphosphonate Therapy
   C. Sodium Fluoride
   D. Continued Estrogen Replacement Therapy
   E. Calcium and Vitamin D supplementation

8. A 45 year old diabetic man on dialysis for 15 years with end-stage renal disease (ESRD) develops a fracture in his left hip. He has been on calcium and calcitriol therapy for many years. He also has a history of hypothyroidism for which he receives L-thyroxine. His TSH has been in the normal range for 10 years. Which of the following likely did NOT contribute to brittle bones in this patient [8] ?

   A. Aluminum in the dialysate fluid and in phosphate binders
   B. Chronic Metabolic Acidosis
   C. Hypothyroidism
   D. Hyperparathyroidism
   E. Adynamic Bone Disease

9. Which of the following is NOT associated with osteonecrosis [9] ?

   A. Hyperparathyroidism
   B. Cushing's Syndrome
   C. Hemoglobin SC Disease
   D. Gaucher's Disease
   E. Alcoholism

10. Osteopetrosis, or marble bone disease, is caused by a defect in [10]:

    A. Osteoblasts
    B. Osteoclasts
    C. Chondrocytes
    D. Calcium Deposition
    E. Cartilage Resporption

Answers

1. B
2. B
3. B
4. A
5. E (Low grade fever, high ESR with normal renal function and calcium.)
6. D
7. C
8. C (Hyperthyroidism can cause brittle bones.)
9. A
10. B (Failure of osteoclasts to remodel bone.)